Human rights violations among men who have sex with men and transgender people in South Africa

Background Men who have sex with men (MSM) and transgender (TG) people face human rights violations (HRVs) which impact their access to critical interventions for HIV prevention, treatment, and related services. Objectives This study describes how Beyond Zero, a not-for-profit organisation in South Africa, built an HRV reporting system and discusses data on the HRVs experienced by MSM and TG people who accessed HIV prevention services between 01 January 2021 and 31 December 2021. Method This was a cross-sectional study using secondary analysis of programmatic data routinely collected as part of HIV prevention programmes for MSM and TG in 10 rural districts of South Africa. Results A total of 249 individuals reported having experienced HRVs. Of these, 113 (54.6%) were physical violations, 145 (58.2%) were psychosocial harassment, 15 (18.3%) were experienced within the workplace, and 59 (23.7%) were experienced at a healthcare or social services institution. Overall, 77% of the physical violations and 70.4% of the psychosocial violations occurred in the home and local community settings; 76.1% of the perpetrators of physical violence and 79.3% of the perpetrators of psychosocial harassment were known. Most incidents of physical violence (80.5%) and psychosocial harassment (92.4%) were not reported due to fear of homophobic or transphobic violence. Conclusion Our findings demonstrate the feasibility of documenting HRVs among MSM and TG people within HIV prevention programmes. Men who have sex with men and TG people should be systematically screened for HRVs and linked to legal or other services. What this study adds Our findings present data on the nature of HRVs in 10 districts outside of the large urban centres where research documenting the lived experiences of MSM, TG people and other key populations is traditionally conducted in South Africa. This data contribute to addressing the gap in the literature on the needs of MSM and TG people in South Africa caused by the delayed inclusion of rural MSM and TG people in research.


Introduction
South Africa has one of the highest burdens of HIV globally, with an estimated 7 800 000 people living with HIV in 2020. While South Africa has a generalised HIV epidemic, the prevalence rates are highest among key populations. 1,2 Uptake of HIV-related treatment and prevention services and retention in care also varies, with lower rates reported among sex workers, men who have sex with men (MSM) and other vulnerable populations. Human rights violations (HRVs) affect this situation by driving the HIV epidemic, contributing to significant vulnerabilities to new infections and presenting barriers to access to HIV prevention and treatment services. 3,4,5 Consequently, this article focuses on documenting HRVs within the context of comprehensive HIV prevention programmes for MSM and transgender (TG) people in 10 districts in South Africa.
Stigma, discrimination, gender inequality and socio-cultural norms that drive physical and sexual violence and psychosocial harassment against key populations create barriers to accessing healthcare and social services, and negatively affect retention in care for the very populations most in need. 3,4,6,7,8,9 These violations also negatively affect employment opportunities and relationships in their communities. To address these disparities, public health experts and funding agencies have redefined the right to health to include creating an environment that affirms the dignity of key and vulnerable populations. In addition, funding agencies have increased investment in programmes to remove human rights-related barriers to HIV-related prevention and treatment services. 3,7,9,10,11 The National Strategic Plan (NSP) for HIV, tuberculosis (TB) and sexually transmitted infections (STIs): 2017-2022 recognises that: there are still important gaps to close with respect to the full implementation of the human rights agenda, particularly the rights of people living with HIV and TB and key and vulnerable populations. 8 (p. 32) Goal 5 of the NSP aims to ground the response to HIV, TB and STIs in human rights principles and approaches, to reduce stigma and discrimination, ensure equal treatment for all and increase access to justice in the context of HIV, TB and STIs for all vulnerable and key populations. 2,8 The NSP 2019-2022 sets out key programmes to reduce human rights-related barriers to HIV and TB services and gender inequality in South Africa. Several interventions are implemented by governmental, non-governmental and private sector stakeholders to ensure the protection and promotion of HIV-related human rights in the country. It is against this background that Beyond Zero (BZ), a not-for-profit organisation in South Africa, developed a system for recording and responding to HRVs against MSM and TG people to strengthen its human rights programming. This study aimed to describe the nature of HRVs experienced by MSM and TG people within the context of comprehensive HIV prevention programmes for MSM and TG people in 10 districts in South Africa.

Study design
We conducted a cross-sectional study using secondary analysis of routinely collected programmatic data under the MSM and TG comprehensive HIV prevention programmes implemented by BZ through sub-recipients (SRs). We used both quantitative and qualitative methods. Quantitative data were collected by determining the number of verified violations reported to BZ by programme staff from the implementing SRs from 01 January 2021 to 31 December 2021. Qualitative data were collected by considering the cases of MSM and TG people reported to BZ by SRs in respect of the nature of the violations and factors surrounding the violations, such as the identity of perpetrators, the location where the violations occurred, and the steps taken by SRs to address reported violations.

Study setting
Beyond Zero implemented the MSM comprehensive HIV prevention programme in nine districts through five SRs and the TG comprehensive HIV prevention programme in four districts through four SRs during the grant period 01 April 2019 to 31 March 2022. Figure 1 highlights the geographic spread of the MSM and TG programmes across South Africa.

Intervention description -Screening, documenting, and reporting human rights violations
In the absence of a national system to systematically document and report HRVs among key populations, BZ used results from a desktop review of NSP, national policies, and the national stigma index to develop the HRV Documentation and Reporting System between October 2020 and December 2020. During this time, the Programme Management Team and Strategic Information Unit created the HRV documentation forms, developed the system's electronic data capture forms and determined how the system would integrate with existing BZ reporting and data management systems. In addition, the team identified how to address user  The HRV monitoring and reporting system is based on a conceptual framework that outlines the following: (1) the necessary activities at the SR level, (2) individual case management strategies, (3) individual-level data collected at the SR level, (4) the use of de-identified data to improve programme implementation, and (5) mechanisms for reporting de-identified data to inform policy and action. Figure 2 outlines a high-level summary of the conceptual framework.
While the system could potentially allow individuals to report the HRVs online, the initial phase focused on the SR staff screening for and documenting HRVs experienced by MSM and TG people using an opt-out approach. The approach of in-person screening conducted by trained SR staff allowed the respective service providers to provide or refer individuals who experienced HRVs for psychosocial, legal and other related support services.
To improve data security and maintain client confidentiality while documenting HRVs, BZ and SRs avoid collecting identifying information in paper or electronic forms. At a minimum, the SRs collect contact information on a separate de-linked form (e.g. client records) with the client's unique identification number to track service provision or referral for off-site services. In addition, the SRs allow clients to provide information in a private space and only report deidentified data to BZ. These data are stored on a secure server with encryption (SurveyCTO ® ), with user access control. Beyond Zero has no access to any personally identifiable information that could potentially be used to identify a particular person. In addition, the units of analysis are the districts, which are large enough that it will not be possible to infer information about individuals based on aggregate reports.
Once a case is documented, each SR provides direct psychosocial support or other appropriate services or linkage to care and support at other organisations or institutions that are better equipped to handle them. For example, SRs refer assault cases to the South African Police Services (SAPS) and work with legal service organisations to ensure their legal cases are reported to appropriate authorities.
Beyond Zero launched the system in December 2020 and conducted two primary interventions between the launch and January 2021. First, BZ trained SR staff to sensitively manage cases of discrimination and HRVs against MSM and TG people and use the reporting system. Second, BZ strengthened the internal relationships between the MSM and TG programmes with the Community Response and Systems Strengthening programme. The linkage with the Community Response and Systems Strengthening module allows for efficient dissemination of the reports and findings among the provincial and district stakeholders, for example provincial councils on AIDS, district AIDS councils, local AIDS councils, and civil society sector representatives.
These data are also reported to the Aids Foundation South Africa (AFSA), which was coordinating the Global Fund human rights programme for all the implementing principal

Data collection instrument and case definitions
For purposes of monitoring and documenting HRVs, BZ developed a detailed screening form through iterative rounds of inputs from programme technical leads and feedback from SR staff, some of whom identify as MSM or TG (Online Appendix 1). Recall of the HRVs experienced and characteristics of the perpetrators were elicited during risk assessment. Table 1 summarises the key questions and case definitions developed following a literature review.

Data collection and analysis
The data from SRs were captured electronically into an online SurveyCTO ® form. The authors used SurveyCTO ® 's built-in Data Explorer to summarise the data submitted for individual fields, summarise the empirical relationships between fields, and drill down to browse individual submissions. The qualitative responses were analysed using thematic content analysis.

Ethical considerations
This study involved secondary analysis of routinely collected HIV prevention programme data that were collected as part of routine programme service delivery. Beyond Zero obtained ethical clearance for this study from the Pharma-Access Health Research Ethics Committee (Ethical Clearance Reference No. 210223835).

Location where human rights violations experienced and the identity of the perpetrators
A review of the reported cases revealed that 51.3% of the physical violations occurred in the home, followed by 25.7% occurring on the streets within the local community. In comparison, the psychosocial violations occurred equally in the home (34.5%) and the streets within the local community (35.9%). Other incidents of physical attacks occurred in bars or nightclubs (15.9%), educational institutions (8.9%), workplaces (4.4%), parks (0.9%) and public transport (0.9%). Other incidents of psychosocial harassment occurred at educational institutions (10.3%), bars or nightclubs (5.5%), workplaces (4.8%), public transport (3.5%) and shopping malls or similar (2.1%).

Barriers to reporting physical and psychosocial violations
All individuals who reported experiencing HRVs where asked if they had reported these violations to the SAPS or any relevant authority (e.g. institutional heads). For those who did not report to SAPS or other relevant authorities, the reasons for not reporting were elicited using predefined categories, with allowance for other reasons to be specified as free text.

Discussion
We analysed routinely collected programmatic data to examine the nature of HRVs among MSM and TG people in 10 districts in South Africa. The individuals who experienced HRVs in our programmes were mainly young MSM and TG people with a mean age of 26 years and a fair level of education (92.8% had secondary education or higher). Our findings are similar to observations in several sub-Saharan African countries that young MSM and TG people are especially vulnerable to HRVs. 6,12,13,14,15,16 Most perpetrators of physical violence and psychosocial harassment were known by the individuals experiencing HRVs, as these occurred in the home and on the streets within the local communities. Similar findings were reported among MSM in Tanzania, with verbal and moral abuse being the most prevalent from people in the street, neighbours and family members. 13 In addition, there is evidence that sexual behaviour stigma at a community level is associated with individual-level risk behaviours among MSM and TG people. 6,17,18 These high rates of HRVs by known perpetrators in the home and community, as well as the association between homophobic behaviour and individual-level risk behaviours, support the need for evidence-informed community-level interventions addressing stigma and discrimination in a culturally sensitive manner.
Of particular interest is that most incidents of physical violence (80.5%) and psychosocial harassment (92.4%) were not reported for mediation or action: 52.6% of the incidents of physical violence and 37.3% of the incidents of psychosocial harassment were not reported due to fear of homophobic or transphobic violence. These findings suggest that while South Africa has a progressive constitution protecting individual rights, the legal framework is insufficient to safeguard MSM, TG people and other key populations who continue to face stigma and discrimination while accessing healthcare and other social services. While not explored in our initial phase of the project, there is evidence that community-level homophobia and concealment of sexual orientation or sexual identity impact mental health, affecting access to, uptake of and retention in HIV prevention services. 6,15,18 Our findings support the need for legal and social change interventions to change attitudes regarding sexual minorities and address stigma, discrimination and HRVs affecting MSM, TG people and other key populations. This requires the rapid scale-up and monitoring of the implementation plan outlined in the NSP to reduce human rights-related barriers to HIV and TB services in South Africa 2019-2022. The implementation plan outlines seven critical programme areas to address HIV, TB and STI-related HRVs comprehensively by (1) reducing stigma and discrimination, (2) sensitising and training health and community workers, (3) sensitising lawmakers and law enforcers, (4) launching legal literacy and know your rights campaigns, (5) strengthening legal support services, (6) monitoring, reviewing laws and policies, (7) reducing gender inequality, and (8) addressing gender-based violence.
The South African constitutional, legal and policy framework creates a conducive environment for governmental, nongovernmental and private sector stakeholders to ensure the protection and promotion of HIV-related human rights in the country. Additionally, the Prevention and Combating of Hate Crimes and Hate Speech Bill is currently under development.
The bill provides grounds for the prosecution of people who commit the offence of hate crime and the offence of hate speech and provides for appropriate sentences that may be imposed on people who commit hate crime and hate speech offences, as well as provides for the prevention of hate crimes and hate speech. 19 This study has important limitations. First, the uptake of the intervention differed between implementing SR and across districts. Second, there was no routine screening for HRVs among all MSM and TG people seeking HIV prevention services. Therefore, it is likely that the HRVs are underreported, and the results from this study may not generalise to MSM and TG people in other districts in South Africa. Third, the cross-sectional study design is limited in inferring causal associations.

Conclusion
Our findings demonstrate the utility and feasibility of screening for and documenting HRVs among MSM and TG people within the context of HIV prevention programmes. The findings suggest the need to systematically screen MSM and TG people of HRVs and link them to legal or other services through a trusted mediator as a standard of care using a rights-based approach that safeguards the dignity and safety of each individual accessing HIV prevention services.
Most of the incidents of HRVs occurred at home, or within family and local community settings, and most were not reported to the authorities for action or mediation. Thus, while the legal basis for redress is necessary, developing the capacity of community-based monitoring systems and structures for mediation is critical for safeguarding and promoting the human rights of MSM and TG people in the country. Finally, addressing HRVs requires adequate funding to support the operationalisation of the comprehensive NSP to reduce human rights-related barriers to HIV and TB services in South Africa 2019-2022 as outlined.